Best surgical practices: a stepwise approach to the University of Pennsylvania deep brain stimulation protocol.
Kramer DR, Halpern CH, Buonacore DL, McGill KR, Hurtig HI, Jaggi JL, Baltuch GH. Best surgical practices: a stepwise approach to the University of Pennsylvania deep brain stimulation protocol. , Neurosurg Focus. 2010 Aug; 29(2): E3
This article discussed a step by step approach to how the University of Pennsylvania’s Movement Disorder Clinic works with DBS patients in order to best improve motor function and minimize adverse events. The authors initially discussed preoperative preparation, which includes choosing patients carefully in order to have a successful intervention. They noted that good prognostic indicators include: "a PD diagnosis, medication responsiveness, tremor, bradykinesia, rigidity, frequent on-off fluctuations, and decreased functional on-times." Indicators of poor surgical outcomes include: "moderate to severe cognitive decline and other Parkinsonian syndromes" (e.g. Parkinson plus syndromes). If patients are deemed appropriate, they then undergo a battery of lab tests and a physical exam. A multidisciplinary approach is used for appropriate surgical candidate selection. On the day of the surgery, the emphasis truly becomes precision of the intervention. To assist with developing precision, a specialized frame is placed on the head of the PD patient in order to hold the patient’s head in place for imaging and surgery. Each patient undergoes an MRI with continual and specific measurements (detailed information is available in the article) made in order to contribute to surgical precision. The authors continued to discuss specific techniques during patient prep as well as actual surgical interventions (e.g. incisions, lead placements, and studies to conduct during the procedure). After the leads are placed in the brain, the battery pack of the stimulator is then placed in the right side of the patient’s chest wall. The authors also described postoperative care including restarting medications, imaging, and restorative therapies. Programming of the device typically occurred between 10 days and a few months following surgery with the concurrent goal of medication reduction. It is very admirable of the University of Pennsylvania to thoroughly discuss their methodology with the goal of improving the outcomes of this effective surgical intervention. The authors were also upfront about their nonpermanent adverse event rate of 12.6% (4.6% for permanent adverse events), which is relatively low. It is imperative that successful Movement Disorder treatment teams follow the University of Pennsylvania’s lead in sharing their methodology in order for other treatment centers to have similar levels of success for PD patients.